00040159 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: O ' 6q
RIIILDING ADDRESS; JO^,�.Ph h r G/ —T—fl fi /N —!
I � MaDZI77 � r `✓U1� A (�AI�1��/��s�/t��—� SANITARYNO. APPLICATIONSUBMITTAL DATE
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'CHITECT(ENGINHER a BULUING PERh11T INFO
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'6^ LICENSED CON'TRACTOR'S DECLARATION
I hereby aRrm that 1 am licensed under Provisions of Chapter 9(commencing Job Description
wobS«uon]000)ofDivision3ofthe Business and Profearions Cede.and my homaeis
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Date —3 cono-.el«
a.O� ARCHITECTSDECLARATION
e <S h bused.Public retards
u Sar O O Licensedss� al
y e OWNER-BUILDER DECLARATION
1 bertbY amt that 1mpr In nefrom the ConramaracroYs License law for the
5 p following reason.(Section]W L5.Business and o,aCade:Any ciry a army
Po winch requires a permh in cowtwm, mr
.I .impova.daman
.ugh,or repair y struma [, F
e - Sq. Floor Area I ,V uati(jn
prim m its isauarce,also requires the applicant for such pvnul to file a signed statement
that he is licensed pursuant m the puvis,ns of the Connlmtg License Law(Cupar,9
(commercial,widsSection]DOB).fDivision3oftheBusinessandPr.fe,rionscode)or APNNumb Occupancy Type
Wt he is esc al,thea(mm and the basis for the alleged exemption.Any violada of
Section]031.5 by any eMile ,fora pennon subjects the applicant t.a civil penalty of 5
Dt more than five hundred dollars(1500).
I.-own-of the property,or my employees with wages as Neu sole compcwtion. Required Inspections
will do the work,and the structure is not imetded or offered for We(Sec.]MC.Buaiecu
and ProfeadoM Cade:The contractor's License taw does Dire apply to an owner of
property wW Wilds or impaves thsuch improvements pr who don wne wok himself of emnugh
Ns own employees,provided Nan such w as net intended a offered for
aWe.
m.however,Ne Wildingoren of prmem Is gold dill Out
eild rinimple for the
owner-Wilda will Nrc tW When of proving that he did not Wild a improve for pa-
poseufWe.).
❑1,I owner of this property,ant exdugively convecting with licensed conracmrs to
consone,I the projecl(Sec.7044.Bull.,and Prufessiom Code:)The eooractors Li.
cense Law does nm apply m an owner of propany wW Wilds or improves Merton,and
who WMK6 far such projects with a coneracnoHx)horn"raiment to'be ContlNoges /
LicanseLaw. .
❑1 am exam,,under Sec. .B&PC fa this reason O
Owner Dene
WORKER'S COMPENSATION DRCLARATION
I hereby affirm under paW ty of p ryry one of on,following dalannioes:
❑1Mese and will for
n37W of me Usage
for the efformacn Of the _
.Donn,as provided fa mi Section 3]OD of the Labor Code.for the pAomunce of the
r which this permit is iuuW.
wort have La will
ee. n pr Campnuficarromm. cM by Sas,,
3](qofrhe laWCar ,for he efformwaofthe work for which his pnnonis
iswd.
My W xstn/ya9c curie and PalicYareA f\ �V1A� /1
C Ll /f—Policy No.: ALLY—VIJIJt�
ERTIFlCATE OF EXEMPTION FROM W00.KER5'
h��q}��J�� D COMPENSATION INSURANCE
1 `�(Tho�seCom xdrwt be corepteted if the permit is for one hundred Mi.(S IW) .
or lass.)
I certify that in the,performame of the work for which Nia permit is issued,I shall
non employ any person many manor m as no become subject to the Workers•compete-
action Laws of California.Data
Applicem
NOTICE TO APPLICAT:If after matin{this Certificate of Exemption,you should
become subject to the Wakces Compensation Provisions of the Labor Cade,yen must
forlhwid,comply wit such provisions ser this permit thall be domed avoked.
CONSTRUCTION LENDING AGENCY
O Ihereby affirso Nca is a commumon leading ageray for man
the of ,
Z 2 the work for which thin permin is issued(Sec.3097,Civ.C.)
4 landau Name
Lenders Address
[gJI certify that I have read this application and Lal.than the above bdonation is
Gx A m.,.l{gone m comply wilh all ciry and county ardi anal and sum laws relating In
,7 Z Wilding comtmcuot.and hereby aahoriu apreamingdes of this city he enter upon Ne
U 0 above.memiond properly for inspection purposes.
W F,. (We)arm m gave,indemnify and kap harmless he City of Cupenlno against
U babilideg.jud,moca ,mots andnpenses which may in my way aarue-Is-Will City
iyr W in consequence of rhe granting of this permit.
U AI AN'I'UNDI?,I2�5�I_AfNUS ANTI R'l1.L COMPLY WITf1 A1.1/O IINT
/00 ^� e
s( r cD u'1 1 /77N6O 4 V
SWu�ol ppl anrConractm Dam 3
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant.,famre Wilding..,notmore.r handle housed.,mmedal Re-roofs
as defined by the Cuplmmo Mum 1 Code,Chapmr 9.12,and the Heath and Safely Type of Roof
coda Sat,,a5s32W YP
❑Yes No
Will the plicanturftmm���///Illding rccupamusecquipmem w devices which All roofs shall be inspected prior to any rooting material being
cast hamdoux air c.nbmivnu ydCfincd by Ne Bey Arca Air Qualay Menugemenn installed. If a roof is Installed without first obtaining an inspection
District? '/ I agree to remove all new materials for inspection. Applicant
❑Ya Na d
Iha.e tesd Ne h.rerdoax m.�;ala agaiamenm ander Gh.ptenbgS.r Ne Gari- un erstangaDd will comply with all non point source regulations.
forma How&Safety Cad=,sections 25505.25533 and]553x,1 uM=nund thin if the
Wild, don cartennyhav=a nam.the bis rein asponnibilirymnai(y the acupant L� U
ofsaw rcnpiwtuuwarceofac if te
Signat gef Applicant Date
aro auth .gen Dam
All roof coverings to be Class"B"or better
OFFICE